Physician Adoption of Electronic Health Records Still Extremely Low, But Medicine May be at a Tipping Point

Despite the promises it offers health care and quality improvement, only a small minority of U.S. physicians have embraced electronic health records (EHR) as a routine part of practice, says a study in the June 19 online edition of the New England Journal of Medicine. The survey of 2,758 physicians—the most up-to-date and comprehensive picture of EHR adoption trends—shows that only 4 percent have a fully functional EHR system and 13 percent have a basic one.

"It is troubling to see just how slow physicians are moving to adopt this technology," says David Blumenthal, M.D., director of the Institute for Health Policy at Massachusetts General Hospital and co-author of the study. "We need to get moving a lot faster than we have been if we are going to take full advantage of this technology and realize its promise for medicine," he says.

The findings come as the federal government is taking steps to accelerate adoption. Last week, Department of Health and Human Services Secretary Michael O. Leavitt announced that Medicare was providing $150 million to 12 cities and states to help more physicians adopt electronic health records. The five-year effort is expected to help as many as 1,200 small practices around the country switch from paper to digital recordkeeping.

Lead study author Catherine DesRoches, an assistant in health policy at Massachusetts General, says getting more physicians to embrace and tout EHRs is critical to breaking down the resistance to using this technology. And while adoption trends today are "very sobering," DesRoches says she sees glimmers of hope.

The survey shows that 16 percent of physicians said their practice had purchased an EHR but had not employed it yet. Another 26 percent said their practice was planning on purchasing a digital recordkeeping system within the next two years. "Should that actually happen, we may be at a tipping point and we'll see a significant jump in adoption by then," says DesRoches.

Blumenthal, DesRoches, and a team at Massachusetts General Hospital, Weill Cornell Medical College, and the George Washington University School of Public Health and Health Services, conducted the nationally representative survey between September 2007 and March 2008. The study was funded by the federal Office of the National Coordinator for Health Information Technology. In addition to looking at adoption rates, researchers sought to find out whether physicians find EHRs useful for practice, and the effect they have on patient care. The authors define a fully functional electronic health record as one that has a broad range of capabilities including order entry capabilities and clinical decision support. A basic EHR is one with a minimum set of functionalities such as recording laboratory data and clinical notes and electronic prescribing.

What Determines Adoption?

EHR use is much more prevalent among younger physicians, primary care physicians, physicians in larger practices, hospitals and medical centers, and in the Western part of the United States. Physicians who serve a higher proportion of minority, uninsured or Medicaid patients were equally likely to have an EHR as others.

Practice size and setting continues to play a big role in whether or not a physician adopts one. Physicians who practiced in groups of at least 50 were three times more likely as those in very small practices (3 doctors or less) to have a basic EHR. Nevertheless, only a minority of physicians in these larger groups (17 percent) had a fully functional EHR and 49 percent did not have an EHR at all.

Cost and complexity are key barriers. Two-thirds of physicians without EHRs cited affordability as the reason they don't have an EHR. Other reasons included finding the right EHR, concern about return on investment and that the system will become obsolete quickly.

Finding the Tipping Point

Physicians who use electronic records say they do make a difference for patients. Those with fully functional EHRs report being satisfied with their system, with large majorities saying it helped improve the quality of clinical decisions, helped them communicate more effectively with other providers, and facilitated prescription refills and avoidance of medical errors. Having a full electronic record also had positive effects on the delivery of chronic and preventive care, helped doctors avoid problematic medication interactions, and promoted more efficient ordering of critical lab tests.

Still 1 in 5 physicians expressed reservations about ease of use and reliability of their systems, suggesting that a significant proportion may encounter problems with their EHRs. Improving the usability of EHRs may be critical to the continued successful diffusion, the authors add.

What Will Enhance Adoption?

Further adoption may be enhanced by helping doctors buy an EHR either through loans, incentive programs, or directly paying them, according to the survey, as well as protecting them from personal liability for record tampering by external parties. Other western countries have taken some of these steps and it seems to have made a difference.

With the switch to digital records costing as much as $60,000 for individual doctors or small practices, achieving widespread adoption undoubtedly will cost a lot of money—a reality that may deter efforts to quicken the pace. In addition to President Bush, the presidential candidates have endorsed greater diffusion of electronic records in practice as part of their health reform plans. Medicare also is pushing health information technology adoption incentives for physicians to spur greater use. While the authors say these incentives "could be important facilitators of adoption," cost will likely be in the tens or hundreds of billions of dollars. Whether future administrations want to take this on, remains to be seen, they conclude.

For copies of the survey, "Electronic Health Record Adoption in the Ambulatory Setting: Findings from a National Survey of Physicians," contact Isha Mehmood at Burness Communications, imehmood@burnesscommunications.com or (301) 652-1558. The executive summary of a forthcoming report, Health Information Technology in the United States: Where We Stand, 2008, funded by the Robert Wood Johnson Foundation and co-authored by the Institute for Health Policy at Massachusetts General Hospital and George Washington University, is available. The full report will be available in early July 2008.

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 30 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. By helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in our lifetime.

The Institute for Health Policy (IHP) at Massachusetts General Hospital and Partners Health System is dedicated to conducting world-class research on the central health care issues of our time. The mission of the IHP is to improve the health and health care of the American people through conducting health policy and health services research, translating new health care knowledge into practice, informing and influencing public policy, and training scholars and practitioners of health policy.